Received: 16 May 2019

| Revised: 24 August 2019

| Accepted: 15 October 2019

DOI: 10.1111/ipd.12589

ORIGINAL ARTICLE

Analysis of survival and factors associated with failure of

primary tooth pulpectomies performed under general anaesthesia
in children from South China

Yu Chen1 | Huixian Li2 | Mianxiang Li1 | Liuqing Yang1 | Qiyin Sun1 |

1,3
Ke Chen

1
Department of Stomatology, Guangzhou
Women and Children’s Medical
Center, Guangzhou Medical University,
Guangzhou, China
2
Institute of Paediatrics, Guangzhou Women
and Children’s Medical Center, Guangzhou
Medical University, Guangzhou, China
3
Stomatological Hospital, Southern Medical
University, Guangzhou, China
Correspondence
Ke Chen, Department of Stomatology,
Guangzhou Women and Children’s Medical
Center, Guangzhou Medical University,
Guangzhou, China.
Email: 2579599833@qq.com
Abstract
Background: Pulpectomy is a technique recommended for treatment of irreversible
pulp inflammation or necrosis. Treatment‐related variables and patient factors may
affect the prognosis of pulpectomy.
Aim: To investigate the survival and related predictors associated with failure of
pulpectomies performed under general anaesthesia for early childhood caries.
Design: Dental records of 124 patients, who underwent pulpectomy as part of
comprehensive dental treatment under general anaesthesia, were reviewed and assessed.
Relapse of pulpitis and periodontal periodontitis were evaluated by clinical examination
and periapical film assessment at each follow‐up appointment after original treatment.
Results: A total of 389 teeth of 124 children were evaluated. By the end of the fourth
year, 45% of teeth with pulpitis and 46% of teeth with periapical periodontitis were
estimated to relapse; the median (interquartile range) number of years to relapse was
3.5 (3.4‐3.8) and 3.0 (1.8‐3.0) years, respectively. The follow‐up frequency, number
of teeth extracted, plaque index, tooth position, type of restoration, pulp status, and
quality of root canal filling were observed to have independent effects on relapse.
Conclusion: Recurrence came earlier in teeth diagnosed with periapical periodontitis
than those with pulpitis. Both treatment‐related variables and patient factors could
affect the prognosis of pulpectomy.

KEYWORDS
dental general anaesthesia, primary teeth, pulpectomy

1 | IN T RO D U C T ION those with extreme anxiety who need extensive rehabilitation

Dental general anaesthesia (DGA) refers to dental rehabilita-
tion treatment under general anaesthesia provided to paedi-
atric patients who may not tolerate routine dental treatment,
according to the American Academy of Pediatric Dentistry
(AAPD). Very young paediatric patients, those with physical,
mental, cognitive, or emotional immaturity or disabilities, or
Chen and Li contributed equally to this work.
are treated under DGA.1 It is generally agreed that compared
with conventional dental treatment using restraints, DGA is
safer and more effective.2,3 Although comprehensive dental
rehabilitation under DGA has been offered to the paediatric
population for nearly three decades, there are however very
few reports regarding long‐term follow‐up evaluation, espe-
cially the effects of DGA on pulpectomy.

Int J Paediatr Dent. 2020;30:225–233. wileyonlinelibrary.com/journal/ipd © 2019 BSPD, IAPD and John Wiley & Sons A/S. | 225
Published by John Wiley & Sons Ltd
226
|    CHEN et al.
Pulpectomy is an endodontic technique recommended for
the treatment of irreversible pulp inflammation or necrosis
caused by dental trauma or caries and is considered a con-
servative option compared with tooth extraction.4,5 The main
goal of this endodontic intervention is to recover the function
of the affected tooth by treating or preserving the integrity of
the periapical tissue and to prevent subsequent reinfection by
eliminating microorganisms from root canals.6
Although most randomised clinical trials have reported
satisfactory success rates for primary tooth pulpectomy,7-9
these studies included procedures performed without seda-
tion or general anaesthesia. Thus, the results may have been
influenced by the cooperation and compliance of the patients.
Moreover, these studies were generally conducted with one
or more applications of intracanal medication10; the progno-
sis of pulpectomy performed under DGA without this process
has yet to be determined.
To date, there is no available information regarding the
clinical factors potentially associated with failure of pulpec-
tomy performed under general anaesthesia in populations at
high risk for caries. Therefore, the aim of this study was to
evaluate the survival rate and factors associated with failure
of primary tooth pulpectomy performed under general an-
aesthesia, with the goal of improving the clinical efficacy of
paediatric dental treatment.
2 | M AT E R IA L S A N D ME T HODS
2.1 | Patients
This retrospective study conducted with ethical approval from
the Institute of Pediatrics Ethics Committee of Guangzhou
Women and Children's Medical Center (reference num-
ber 2012110520), and in accordance with the Helsinki
Declaration as revised in 2013. Written informed consent to
use patients’ data was obtained from the parents or guardians.
2.1.1 | Inclusion criteria
Children (aged 2‐8 years, American Society of
Anesthesiologists Class I and II) who received dental
treatment under DGA from 2013 to 2016 were included in
the study. Dental treatment included pulpectomy under DGA
and comprised more than one post‐operative check‐up visit.
The criteria for case selection were irreversible pulpitis,
necrotic pulp, or periodontal periodontitis as follows: (a)
deep carious lesion involving pulp and bleeding that did not
halt within five minutes following removal of the coronal
pulp tissue, (b) history of spontaneous pain, and (c) apical
fistula or abscess and radiographic evaluation revealing that
furcation or periapical radiolucency with roots exhibiting
minimal or no resorption and permanent tooth germ being
affected (as per the AAPD 2015 guidelines).
Why this paper is important to paediatric dentists
• Both treatment‐related variables and patient factors
can affect the prognosis of pulpectomy.
• The long‐term survival rate of pulpectomy is lower
than expected.
• Special attention needs to be paid to children and
teeth with poor plaque control, unshaped or necrotic
dental pulp, low compliance, and a large number of
extracted teeth.
2.1.2 | Exclusion criteria
Children who underwent DGA for non‐pulpectomy
procedures (eg, tooth restoration, pulpectomy or partial
pulpectomy, removal of teeth or impacted supernumeraries)
and those without post‐surgical follow‐up records were
excluded from the study.
2.2 | Treatment and follow‐up
At our institution, it is recommended that all children return for
regular follow‐up every three months until all primary teeth are
replaced with permanent teeth. Clinical status and X‐rays were
evaluated during every follow‐up. Success of the pulpectomy
was defined both clinically and radiographically. The criteria
for clinical success were that patients were completely free
of signs and symptoms including pain, abscess, fistula, and
abnormal mobility. The criteria for radiographic success were
no pathologic external root resorption, and no radiographic
lesions for pulpitis and resorption or stability of any previous
radiographic lesion for periapical periodontitis. Relapse was
defined as the development of pain, fistula or abscess, appearance
or aggravation of periapical or furcation radiolucency, widening
of the periodontal ligament, or pathological root resorption in a
treated tooth.11
2.3 | Data collection
Information acquired for the analysis included the patient's
dental records, and documents related to general anaesthesia
and health history from both electronic and paper documents.
Personal background data included name, gender, and age at
the time of surgery (in months).
Information was retrieved from dental records based on
child‐ and tooth‐level predictors. Child‐level predictors included
age (months) at the time of treatment, gender, systemic history,
duration of operation, number of carious and extracted teeth, fol-
low‐up frequency, and plaque index at the time of failure. Tooth‐
level predictors included tooth position (anterior or posterior),
presence of spontaneous pain before surgery, diagnosis (pulpitis
CHEN et al.   
| 227

or periapical periodontitis, based on AAPD clinical‐radiographic
criteria), pulp condition (shaped or unshaped), use of rubber
dam (KSK Co. Ltd.) and nickel‐titanium mechanical preparation
(Yirui Medical Devices Co. Ltd.), use of 3% sodium hypochlo-
rite irrigation solution (Langli Biomedical Co. Ltd.) during root
canal preparation, quality of root canal filling (adequate, under-
filled, overfilled, for multirooted molar; if one of the root canal
is overfilled or underfilled and the others are adequate, the tooth
will be classified as overfilling or underfilled [filling material:
Vitapex, Neo Dental Chemical Products Co. Ltd.]), type of cor-
onal restoration (resin composite for both anterior and posterior
teeth, striped crown forms for anterior teeth, or preformed metal
crown for posterior teeth [Filtek Z250 University Restoration,
striped crown forms and preformed metal crown, 3M; ESPE]).
Evaluations were performed by the three examiners
blinded to the treatment. When evaluation results differed
amongst examiners, the majority opinion was accepted.
Cohen's kappa coefficient for intra‐examiner reproducibility
of radiographic evaluations was 0.86.
were presented as means (standard deviations, SD) and
compared using the Student's t test. The Kaplan‐Meier method
was used to analyse survival curves and the Wilcoxon test was
used to compare two different curves. The discrete‐time hazard
model,12 which has the advantage that one does not need to
make the assumption that the hazard function is constant within
each interval, was used to estimate the relapse hazard at each
time period. Given the hierarchical structure of the data, the
effects of both child‐ and tooth‐level predictors on relapse
were estimated using a multilevel discrete‐time survival model
with mixed effects using SAS PROC GLIMMIX. All analyses
were conducted using SAS Windows software, version 9.4
(SAS Institute, Inc, Cary, NC, USA). P‐values (P) <.10 were
considered significant and probability values were 2‐sided.
The following formula was used:
[ ]
logit hij (t) = 𝛼 (t) + 𝛽1 xij (t) + ⋯ + 𝛽n xij (t) + 𝜇j
( )
𝜇j ∼ N 0,𝜎𝜇2

2.4 | Statistical analysis

where hij (t) is the hazard of relapse in time interval t during
Categorical variables were presented as numbers (percentage) the ith tooth nested within the jth child, xij (t) are covariates
and compared using the chi‐square test. Continuous variables defined at the child‐ or tooth‐level, and 𝜇j denotes random

TABLE 1 Descriptive statistics of

Recovery Relapsed
child‐level predictors at the beginning of
Predictors n = 69 n = 55 t/χ2 P value*
the study
Age, mean (SD)/mo 50.88 (14.29) 53.84 (16.88) −1.05 .294
Gender, n (%) 1.08 .298
Boy 44 (59.46) 30 (40.54)
Girl 25 (50.00) 25 (50.00)
General health, n (%) 2.45 .118
Good 63 (58.33) 45 (41.67)
Poor 6 (37.50) 10 (62.50)
Duration of operation, n (%) 0.07 .793
≤2.5 h 33 (56.90) 25 (43.10)
>2.5 h 36 (54.55) 30 (45.45)
Follow‐up frequency, n (%) 10.88 .001
≥3 times/y 48 (68.57) 22 (31.43)
<3 times/y 21 (38.89) 33 (61.11)
Sodium hypochlorite, n (%) 0.09 .762
Used 27 (54.00) 23 (46.00)
Not used 42 (56.76) 32 (43.24)
Sum of decayed teeth, mean (SD) 15.19 (3.18) 15.20 (3.54) −0.02 .985
Number of teeth extracted, n (%) 0.14 .710
≤5 57 (56.44) 44 (43.56)
>5 12 (52.17) 11 (47.83)
Plaques in the mouth, mean (SD) 0.83 (0.79) 2.02 (0.95) −7.64 <.001
Abbreviation: SD, standard deviation.The bold P values indicated that the difference between the two groups
reached significant level (P< .10).
*The bold P values indicated that the difference between the two groups reached significant level (P< .10).
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|    CHEN et al.

TABLE 2 Descriptive statistics of

Recovery Relapsed
tooth‐level predictors at the beginning of
Predictors n = 287 n = 102 t/χ2 P value*
the study
Pulpitis, n (%)
Anterior 72 (72.73) 27 (27.27) 0.15 .701
Posterior 195 (74.71) 66 (25.29)
Periapical periodontitis, n (%)
Anterior 6 (85.71) 1 (14.29) 0.40 .528
Posterior 14 (63.64) 8 (36.36)
Type of restoration, n (%)
Resin filled 88 (66.17) 45 (33.83) 6.11 .047
Transparent crown 52 (78.79) 14 (21.21)
Preformed crown 147 (77.37) 43 (22.63)
Pain history, n (%)
No 207 (80.86) 49 (19.14) 19.40 <.001
Yes 80 (60.15) 53 (39.85)
Pulp status, n (%)
Shaped 194 (83.98) 37 (16.02) 30.61 <.001
Unshaped 93 (58.86) 65 (41.14)
Rubber dam, n (%)
Used 198 (74.16) 69 (25.84) 0.06 .802
Not used 89 (72.95) 33 (27.05)
Nickel‐titanium root canal preparation, n (%)
Used 225 (76.79) 68 (23.21) 5.57 .018
Not used 62 (64.58) 34 (35.42)
Canal filling quality, n (%)
Adequate 225 (75.50) 73 (24.50) 2.34 .310
Overfilled 34 (70.83) 14 (29.17)
Underfilled 28 (65.12) 15 (34.88)
*The bold P values indicated that the difference between the two groups reached significant level (P< .10).

TABLE 3 Data for estimating interval and cumulative recurrence for each time period by diagnosis

Interval timea Number of teeth at beginning Number of relapse Interval recurrence (95% CI) Cumulative recurrence (95% CI)
Pulpitis
1st year 360 2 0.01 (0.00, 0.02) 0.01 (0.00, 0.02)
2nd year 332 18 0.05 (0.03, 0.08) 0.06 (0.04, 0.10)
3rd year 187 29 0.14 (0.10, 0.20) 0.19 (0.14, 0.28)
4th year 106 40 0.32 (0.26, 0.39) 0.45 (0.36, 0.56)
5th year 17 4 0.21 (0.09, 0.42) 0.57 (0.42, 0.74)
Periapical periodontitis
1st year 29 1 0.03 (0.00, 0.20) 0.03 (0.00, 0.20)
2nd year 27 6 0.20 (0.10, 0.36) 0.23 (0.11, 0.49)
3rd year 9 1 0.11 (0.02, 0.46) 0.31 (0.12, 0.72)
4th year 4 1 0.22 (0.04, 0.67) 0.46 (0.15, 0.91)
5th year 0 ‐ ‐ ‐
Abbreviation: CI, confidence interval.
a
1st year: 0‐11 mo, 2nd year: 12‐23 mo, 3rd year: 24‐35 mo, 4th year: 36‐47 mo, and 5th yr: 48‐51 mo.
CHEN et al.   
| 229

effects representing unobserved characteristics of the jth

child.

3 | RESULTS

3.1 | Patient and tooth characteristics

F I G U R E 1 Cumulative probability of recovery of primary teeth
pulpectomies performed under general anaesthesia by diagnosis (y)
A total of 389 teeth of 124 children who underwent
treatment under DGA were included in our study. Patient
and tooth characteristics are presented in Tables 1 and 2. The
analysis of child‐related indicators revealed that 55 children
had relapse in at least one tooth after pulpectomy during the
follow‐up period. Children who did not return for a follow‐
up visit as recommended and had more plaques in the oral
cavity were more likely to have a relapse (both P < .05).

TABLE 4 Effect of child‐ and tooth‐

Predictors: Reference β (SE) OR (95% CI) t P value*
level predictors on relapse
Intercept −6.56 (2.83) ‐ −2.32 .022
Year: Fifth year 0 1 ‐ ‐
First year −0.10 (0.69) 0.91 (0.23, 3.51) −0.14 .888
Second year −0.07 (0.69) 0.93 (0.24, 3.60) −0.11 .916
Third year −0.04 (0.69) 0.96 (0.25, 3.74) −0.06 .955
Fourth year −0.03 (0.70) 0.97 (0.25, 3.82) −0.05 .964
Age 0.03 (0.02) 1.03 (0.98, 1.07) 1.18 .240
Gender: Male 0.70 (0.61) 2.01 (0.61, 6.69) 1.14 .253
Health condition: Good 0.89 (0.92) 2.43 (0.40, 14.75) 0.97 .333
Duration of operation: ≤2.5 h −0.48 (0.73) 0.62 (0.15, 2.59) −0.66 .511
Follow‐up frequency: ≥3 times/y 1.85 (0.67) 6.33 (1.69, 23.66) 2.75 .006
Sodium hypochlorite: Not used −0.71 (0.79) 0.49 (0.11, 2.29) −0.91 .365
Sum of decayed teeth −0.17 (0.10) 0.85 (0.69, 1.03) −1.65 .100
Number of teeth extracted: ≤5 1.56 (0.86) 4.78 (0.89, 25.82) 1.82 .069
Plaque index 2.23 (0.41) 9.31 (4.19, 20.67) 5.48 <.001
Principal diagnosis: Pulpitis 0.38 (0.51) 1.46 (0.54, 3.99) 0.74 .459
Site: Anterior tooth −2.12 (0.51) 0.12 (0.04, 0.32) −4.20 <.001
Type of restoration Preformed crowns 0 1 ‐ ‐
Resin filled 0.67 (0.30) 1.96 (1.08, 3.54) 2.21 .027
Transparent crown −0.98 (0.52) 0.37 (0.13, 1.04) −1.89 .059
Pain history: No 0.10 (0.24) 1.10(0.69, 1.76) 0.41 .680
Dental pulp: Shaped 2.07 (0.29) 7.91 (4.51, 13.88) 7.22 <.001
Rubber dam: Used 0.32 (0.50) 1.38 (0.52, 3.67) 0.64 .524
Nickel‐titanium root canal preparation: 1.09 (0.67) 2.98 (0.8, 11.07) 1.63 .103
Used
Quality: Underfilled 0 1 ‐ ‐
Adequate −0.55 (0.31) 0.57 (0.31, 1.05) −1.80 .072
Overfilled −0.34 (0.35) 0.71 (0.36, 1.41) −0.98 .326
*The bold P values indicated that the difference between the two groups reached significant level (P< .10).
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|    CHEN et al.
(A) (B)
(C) (D)
Of the 389 teeth, 102 (26.22%) relapsed after treatment.
The mean follow‐up time of the relapse and recovery groups
was 24.12 ± 11.50 and 24.04 ± 11.27 months, respectively;
the difference was not statistically significant (P = .950).
The differences of recurrence rate in posterior teeth versus
anterior teeth in pulpitis and periapical periodontitis were
not statistically significant (both P > .05). Teeth with dif-
ferent types of restoration had significantly different recur-
rence rates (P = .047). In addition, cases with a history of
pain, with unshaped pulp, or where nickel‐titanium root canal
preparation instruments were not used were more prone to
relapse (all P < .05).
3.2 | Survival and recurrence
For the pulpitis and periapical periodontitis groups, the range
of follow‐up time of censored subjects was 9‐51 months
and 9‐38 months, respectively. The distribution of relapses
over the study period is shown in Table 3. It was estimated
that by the end of the fifth year of follow‐up, relapse would
occur in 57% of all teeth diagnosed with pulpitis that had
undergone pulpectomy. The cumulative recurrence of teeth
diagnosed with periapical periodontitis was 46% by the
end of the fourth year of follow‐up. The hazard presented
F I G U R E 2 A 61‐mo‐old boy who
underwent pulpectomy and other treatment
under general anaesthesia. Left mandibular
second primary molar (75) had pain history,
and pulp was exposed without abnormal
mobility and fistula. Radiographs of 75
after pulpectomy during the 1 y follow‐up
period. A, Before surgery. B, 1 mo post‐
operatively showing adequate filling. C,
6 mo post‐operatively showing the fillings
were slightly resorbed. D, 12 mo post‐
operatively showing that most fillings were
resorbed and the periapical radiolucency
was developed. Relapse occurred 12 mo
after treatment
for each year represents the probability of relapse in that
period, assuming that the teeth had not previously relapsed.
Survival curves of teeth diagnosed with pulpitis show that
relapse rates would suddenly increase from the third year
and were the highest in the fourth year of follow‐up. The
sudden upward trend of relapse in teeth diagnosed with
periapical periodontitis came earlier (Table 3, Figure 1).
Median (interquartile range) years to relapse for teeth with
different diagnoses was 3.5 (3.4 to 3.8) and 3.0 (1.8 to 3.0)
years, respectively. It showed a significantly lower overall
recurrence in the teeth diagnosed with pulpitis (P < .05).
3.3 | Effects of different predictors
on relapse
When all examined parameters were included in the
multilevel discrete‐time survival model, a statistically
significant association was observed between the follow‐
up frequency, intraoral plaque levels at the last visit,
tooth position, type of restoration, and dental pulp status
(P < .05). Further, the number of decayed teeth and root
canal filling quality were also considered to be associated
with recurrence (P < .10). The specific effects are shown in
Table 4. Children who did not return for regular follow‐up
CHEN et al.   
| 231

(A) (B) (C)

(D) (F)

(E) (G)

F I G U R E 3 A 53‐mo‐old boy who underwent pulpectomy and other treatment under general anaesthesia. Left mandibular second primary
molar (75) had no pain history, abnormal mobility, and fistula. The pulp was exposed after removal of caries. Bleeding did not halt within five
minutes following removal of the coronal pulp tissue. Radiographs of 75 after pulpectomy during the 3 y follow‐up period. A, Before surgery. B,
1 wk post‐operatively showing adequate filling. C, 3 mo post‐operatively showing that fillings were slightly resorbed. D, 12 mo post‐operatively
showing that most fillings were resorbed without periapical radiolucency. E, 18 mo post‐operatively showing the most fillings were resorbed
without periapical radiolucency. F, 24 mo post‐operatively showing the fillings were completely resorbed without periapical radiolucency. G,
36 mo post‐operatively showing the fillings were completely resorbed and that periapical radiolucency and fistula had developed. Relapse occurred
36 mo after treatment

visits were 6.33 (OR: 6.33, 95% CI: 1.69‐23.66) times more
likely to experience relapse than children who underwent
4 | DISCUSSION
follow‐ups more than 3 times per year. Children with more
The fourth national oral epidemiological surveys in China
than 5 teeth extractions were also estimated to have a higher
show that the prevalence of caries is as high as 70.9% and the
rate of relapse (OR: 4.78, 95% CI: 0.89‐25.82). Teeth of
mean decayed‐missing‐filled‐teeth (DMFT) index reached
children with more plaques in their mouths and teeth with
4.24 in the 5‐year‐old group in 2015. In the past 10 years,
unshaped dental pulp were demonstrated to have statistically
the incidence and severity of caries in primary teeth has
significant increased odds of experiencing relapse (OR: 9.31,
increased rapidly.13 Pulpitis and periodontal periodontitis
95% CI: 4.19 to −20.67; OR: 7.91, 95% CI: 4.51 to 13.88).
caused by severe caries is the main reason underlying
The recurrence rate in the posterior teeth was 88% lesser
early teeth loss. Early loss of primary teeth may reduce the
compared with that in the anterior teeth (OR: 0.12, 95% CI:
masticatory efficiency and cause malocclusion and eruption
0.04‐0.32). Compared with teeth with preformed crowns,
abnormality.14 Multiple teeth extraction is not the preferred
the recurrence rates of those with resin filling was higher,
option for children with severe early childhood caries.
and those with transparent crowns were lower (P < .10).
Pulpectomy is considered to be a preferable solution as
In addition, adequate root canal filling could reduce the
compared with tooth extraction (Figures 2-4).
recurrence rate by 43% compared with insufficient filling
Success of pulpectomy was defined as both clinical
(OR: 0.57, 95% CI: 0.31‐1.05; P < .10).
and radiographic success in this retrospective study, with
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|    CHEN et al.
(A) (B)
F I G U R E 4 A 55‐mo‐old girl who underwent pulpectomy and
other treatment under general anaesthesia. The right central incisor
(51) had no pain history and without abnormal mobility and fistula.
Radiographs of 51 after pulpectomy during the 18‐mo follow‐up
period. A, 1 wk post‐operatively showing adequate filling. B, 1 y post‐
operatively showing 51 was about to be replaced. Success was still
judged at 18 mo after treatment
failure to meet both healing criteria judged as relapse.
Accordingly, clinical success with radiographic failure
often leads to ultimate failure or Turner's tooth.4 The re-
sults show that treatment‐related variables and patient
factors can affect the prognosis of pulpectomy. In the dis-
crete‐time survival analyses of this study, key factors with
significantly higher odds ratio values were plaque index,
dental pulp status, follow‐up frequency, and number of
teeth extracted. Thus, these factors have significant influ-
ence on the prognosis of pulpectomy.
Principally, bacteria in the root canal space are respon-
sible for periapical periodontitis, with pulp status indicative
of the degree of infection.15 Recurrence rate in teeth with
history of pain and unshaped pulp was higher than that in
teeth without history of pain and shaped pulp, corroborat-
ing the fact that the initial condition of the tooth was as-
sociated with the outcome of pulpectomy.16 The difficulty
of completely eliminating the pathogen from pulp that is
seriously infected even after pulpectomy is the main cause
of recurrence.17 In descriptive statistics of this study, there
was a higher recurrence rate in posterior teeth versus ante-
rior teeth with periapical periodontitis; however, the dif-
ference was not statistically significant. That is probably
due to the multiple root canals and accessory canals at the
bottom of pulp chamber in primary molars. Therefore, in-
fection is more likely to reach the apex and bifurcation of
the root, causing bone destruction. The contrary result was
obtained when time and other factors were taken into ac-
count. It may be related to less number of teeth with peri-
apical periodontitis (Figures 2-4).
Several studies show that most of the failures occur in the
first 3 months following pulpectomy.18 In our study, the re-
covery rate at 3 months follow‐up is quite high. The survival
curve turned steeper abruptly from the third year of follow‐
up. The probability of recovery decreased to 30% from the
fourth year of follow‐up, which is lower than that in other
studies.7-9 Notably, the material used for canal filling in our
cases was ‘Vitapex’, which is widely used in pulpectomy and
contains 30.3% calcium hydroxide, 40.4% iodoform, 27.4%
silicone oil, and 6.9% inert matter. Owing to the high solu-
bility of calcium hydroxide, the reaction time is shorter, but
strength of chelation is slightly lower, leading to more rapid
degradation. Iodoform dissolves easily upon contact with
solution and tissue fluid, thereby changing the structure of
the filling mass to a porous and loose state that might be re-
sorbed more easily.19 Ramar and Mungara reported 56.6% of
teeth treated with Vitapex showed material resorption ahead
of the roots in 9 months.20 This early resorption of Vitapex
may however form a narrow channel for bacterial growth and
contribute to reinfection in the root canal.21,22
This study has some limitations that should be empha-
sised. The retrospective study had no subsequent observa-
tion of succedaneous permanent teeth. The appearance of
Turner's tooth in succedaneous permanent teeth is an import-
ant manifestation of local inflammation of primary teeth.23
Future studies should more closely evaluate the development
of permanent teeth. Moreover, new and better root filling ma-
terials for primary teeth need to be developed.
In conclusion, the prognosis of pulpectomy performed
under general anaesthesia can be influenced by both treat-
ment‐related variables and patient factors. The five‐year sur-
vival rate of pulpectomy is lower than expected. We should
pay more attention to children and teeth with poor plaque
control, unshaped or necrotic dental pulp, low compliance,
and a large number of extracted teeth. Preformed metal or
transparent crowns, nickel‐titanium mechanical preparation,
and adequate root canal fillings are preferred.
CONFLICT OF INTEREST
There are no conflicts of interest to declare for all authors.
AUTHORS' CONTRIBUTION
Yu Chen and Ke Chen conceived the ideas; Yu Chen led
the writing; Mianxiang Li, Liuqing Yang and Qiyin Sun
performed the operation and collected the data; and Huixian
Li analysed the data and participated in the writing.
CHEN et al.
ORCID
Yu Chen https://orcid.org/0000-0003-4063-4086
Huixian Li https://orcid.org/0000-0001-5722-8602
Ke Chen https://orcid.org/0000-0002-9287-6565
R E F E R E NC E S
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How to cite this article: Chen Y, Li H, Li M, Yang
L, Sun Q, Chen K. Analysis of survival and factors
associated with failure of primary tooth pulpectomies
performed under general anaesthesia in children from
South China. Int J Paediatr Dent. 2020;30:225–233.
https​://doi.org/10.1111/ipd.12589​